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Evidence-Based Protocol for Diabetic Foot Ulcers

Brem, Harold M.D.; Sheehan, Peter M.D.; Rosenberg, Harvey J. B.A.; Schneider, Jillian S. M.S.; Boulton, Andrew J. M. M.D.

Plastic and Reconstructive Surgery: June 2006 - Volume 117 - Issue 7S - p 193S-209S
doi: 10.1097/01.prs.0000225459.93750.29
Reconstructive Wound-Healing Supplement: Original Articles: Reconstructive

Background: Diabetic foot ulcers are the single biggest risk factor for nontraumatic foot amputations in persons with diabetes. Foot ulcers occur in 12 to 25 percent of persons with diabetes and precede 84 percent of all nontraumatic amputations in this growing population. Because of the high incidence of foot ulcers, amputations remain a source of morbidity and mortality in persons with diabetes. Strict adherence to evidence-based protocols as described herein will prevent the majority of these amputations.

Methods: The collective experience of treating patients with neuropathic diabetic foot ulcers in four major diabetic foot programs in the United States and Europe was analyzed.

Results: The following protocol was developed for patients with diabetic foot ulcers: (1) establishment of good communication among the patient, the wound healing team, and the primary medical doctor; (2) comprehensive, protocol-driven care of the entire patient, including hemoglobin A1c, microalbuminuria, and cholesterol as well as early treatment of retinopathy, nephropathy, and cardiac disease; (3) weekly objective measurement of the wound with digital photography, planimetry, and documentation of the wound-healing process using the Wound Electronic Medical Record, if available; (4) objective evaluation of blood flow in the lower extremities (e.g., noninvasive flow studies); (5) débridement of hyperkeratotic, infected, and nonviable tissue; (6) use of systemic antibiotics for deep infection, drainage, and cellulitis; (7) off-loading; (8) maintenance of a moist wound bed; (9) use of growth factor and/or cellular therapy if the wound is not healing after 3 weeks with this protocol; and (10) consideration of the use of vacuum-assisted therapy in complex wounds.

Conclusions: In diabetic foot ulcers, availability of the above modalities, in combination with early recognition and comprehensive treatment, ensures rapid healing, minimizes morbidity and mortality rates, and eliminates toe and limb amputations in the absence of ischemia and osteomyelitis.

New York, N.Y.; Miami, Fla.; and Manchester, United Kingdom

From the Department of Surgery, Wound Healing Program, Columbia University College of Physicians and Surgeons; Diabetes Foot and Ankle Center, Hospital for Joint Diseases; Department of Surgery, Columbia University Medical Center; Division of Endocrinology, University of Miami School of Medicine; and University of Manchester.

Received for publication February 7, 2006; revised March 24, 2006.

This work was supported in part by the National Institutes of Health: DK59424 and LM08443.

Harold Brem, M.D., 5141 Broadway, Room 3-020, New York, N.Y. 10034,

©2006American Society of Plastic Surgeons